Chapter 7 Acute and Posttraumatic Stress Disorders, Dissociative Disorders, and Somatoform Disorders Copyright © 2006 Pearson Education Canada Inc.
Dec 19, 2015
Chapter 7Acute and Posttraumatic Stress
Disorders, Dissociative Disorders, and Somatoform Disorders
Copyright © 2006 Pearson Education Canada Inc.
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Overview
Focus: normal vs. pathological reactions to trauma
Anyone might develop a stress/trauma related disorder given the critical level of exposure
Dissociation – disruption of the normally integrated processes of memory consciousness, identity, or perception
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Definition of Trauma
A unique individual experience, associated with an event or enduring condition, in which:
- the individual’s ability to integrate affective experience is overwhelmed or
- the individual experiences a threat to life or bodily integrityL.A. Pearlman and K. Saakvitne
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DSM IV-TR: Defining Trauma
event: actual/threatened death or serious injury to self or others
response: intense fear, helplessness, & horror
emphasizes subjective response
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Types of Trauma
- Sexual Abuse
- Physical Abuse
- War related
- Terminal illness
- Gang Violence
- Natural Disaster
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Characterological Impacts
– Damaged sense of control– Anxiety Dysregulation – Repression– Shame/Guilt– Erosion of Trust
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Acute and Posttraumatic Stress Disorders
Stress: normal aspect of everyday life (Ch. 8)
Traumatic stress: – event that involves actual or threatened
death/serious injury to self or others – Creates intense feelings of fear or horror
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Acute stress disorder (ASD)
– The person has been exposed to a traumatic event in which both of the following were present:
the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
the person's response involved intense fear, helplessness, or horror
within 4 weeks after exposure - the disturbance lasts for a minimum of 2 days and a maximum of 4 weeks
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Acute stress disorder (ASD)
– Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:
a subjective sense of numbing, detachment, or absence of emotional responsiveness
a reduction in awareness of his or her surroundings (e.g., "being in a daze")
derealization
depersonalization
dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
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Acute stress disorder (ASD)
– The traumatic event is persistently reexperienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.
– Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).
– Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).
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Posttraumatic stress disorder (PTSD)
like ASD, characterized by– dissociative symptoms– re-experiencing of the event– marked anxiety/arousal
Unlike ASD, symptoms long-lasting More than 1 monthLifetime Prevalence is 11%
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Posttraumatic stress disorder (PTSD)
The traumatic event is persistently reexperienced in one (or more) of the following ways:
– recurrent and distressing recollections of the event (e.g., images or thoughts).
– recurrent distressing dreams of the event.
– acting or feeling as if the traumatic event were recurring (e.g., includes a sense of reliving the experience, illusions, hallucinations).
– intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
– physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
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Posttraumatic stress disorder (PTSD)
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
– avoids thoughts, feelings, or conversations associated with the trauma
– avoids activities, places, or people that arouse recollections of the trauma
– inability to recall an important aspect of the trauma
– markedly diminished interest or participation in significant activities
– feeling of detachment or estrangement from others
– restricted range of affect (e.g., unable to have loving feelings)
– sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
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Posttraumatic stress disorder (PTSD)
Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
– difficulty falling or staying asleep
– irritability or outbursts of anger
– difficulty concentrating
– hypervigilance
– exaggerated startle response
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ASD & PTSD: Typical Symptoms
1. Re-experiencing trauma 2. Avoidance of associated stimuli 3. Persistent arousal/anxiety4. Survivors guilt
ASD not PTSD: dissociative symptoms
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1. Re-experiencing Trauma
Persistent, horrific images (e.g., nightmares)
Flashbacks – spontaneous memories of trauma
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2. Avoidance
thoughts or feelings about the event associated people, places, or
activities numbing of responsiveness
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3. Arousal/Anxiety
hypervigilance sleep/concentration difficulties irritability heightened startle response
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Historical Perspective
“combat neurosis”“shell shock”interest in PTSD amplifies following
Vietnam War
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Etiology
Social factors– level of exposure– post-trauma social support
Psychological factors– two-factor theory– Classical and Operant conditioning
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Prevention/Treatment
prevention through early interventioncritical incident stress debriefing (CISD)anti-depressants (but not anxiolytics)CBTexposure therapyEMDR
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Dissociative Disorders
persistent problems in the integration of memory, consciousness, or identity
perhaps best interpreted from a psychoanalytic perspective
– Unconscious processes
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Dissociative Identity Disorder (DID)
– formally called Multiple Personality Disorder– 2+ personalities in the same individual – personalities are very different in nature, often representing extremes
of what is contained in a normal person. – At least two of these personalities repeatedly assume control of the
patient's behavior. – Common forgetfulness cannot explain the patient's extensive inability
to remember important personal information. – This behavior is not directly caused by substance use (such as
alcoholic blackouts) or by a general medical condition.
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Depersonalization Disorder
A feeling of detachment from, or being an outside observer of, one's mental processes or body occurs such as the sensation of being in a dream. This phenomena involves:
A lasting or recurring feeling of being detached from the patient's own body.
Throughout the experience, the patient knows this is not really the case. Reality experience is intact.
The disorder is not directly caused by a general medical condition or by substance use, including medications and drugs of abuse.
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Dissociative Amnesia
The predominant disturbance is one or more episodes of inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness.
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Dissociative Amnesia
Selective Amnesia: a person can recall only small parts of events (e.g., victim may recall only some parts of the series of events around his or her abuse.
Generalised Amnesia: is diagnosed when a person's amnesia encompasses this entire life.
Continuous Amnesia: occurs when the individual has no memory for events beginning from a certain point in the past continuing up to the present.
Systematised Amnesia: is characterised by a loss of memory for a specific category of information. A person with this disorder might, for example, be missing all memories about one specific family member.
Dissociative Fugue: a person suddenly and unexpectedly takes physical leave of his surroundings and sets off on a journey of some kind. These journeys can last hours, days or months and can cover thousands of miles. In some cases will assume a new identity
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DID Controversies
problem of self-report
reliability of recovered memories– infantile amnesia– scientific evidence for false memories
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Skepticism regarding DID
most diagnoses by a small number of advocates increased diagnoses following release of Sybil increasing number of personalities in DID cases
(1980 = 200; 1986 = 6000) why only in North America?
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Etiology
Psychological factors– recurring childhood trauma - evaluation of the past from the
vantage point of the present– self-hypnosis – state dependant learning
Biological factors– genetic (conflicting research findings)– Preliminary evidence indicates no genetic contribution
Social factors– Social role theory
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Spanos’ Theory of DID
not a true “disorder”
patients are role-playing – symptoms are iatrogenic – patients develop multiple personalities in response to
the leading questions of therapists, not as a result of a defense mechanism.
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Treatment of Dissociative Disorders
Psychological approach – recovery of traumatic memories
hypnosis
– main objective: integration of personalitiesMedical approach
– distress reduction
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Somatoform Disorders
Problems featuring physical symptoms with no organic basis
perhaps best interpreted from a psychoanalytic perspective– symptoms not faked – unconscious factors
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Typical Symptoms: 3 Variations
single impairment of somatic system (e.g., paralysis, blindness)
multiple physical symptoms (e.g., pain & gastrointestinal symptoms)
Preoccupation with a single disease (e.g., cancer)
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5 types of somatoform disorders
1) Conversion Disorder psychological conflicts converted into physical symptoms symptoms mimic common neurological conditions often inconsistent with accurate anatomical functioning -
therefore, not a medical condition Conflicts or other stressors that precede the onset or worsening
of this symptom suggest that psychological factors are related to it.
The patient doesn't consciously feign the symptoms for material
gain (Factitious Disorder) or to occupy the sick role (Malingering).
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Research on Conversion Blindness
• What happens if a researcher asks a person with conversion blindness to “guess” in a recognition task? (e.g., is the bear on the right or left?)• the person responds at a level
significantly above chance.• malingerers respond at a level below
chance.
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5 types of somatoform disorders
2) Somatization Disorder patient complains of at least 8 symptoms:– four pain symptoms (e.g., back, joints, abdomen)– 2 or more gastrointestinal symptoms (e.g.,nausea, bloating, vomiting)– 1 or more sexual symptoms (e.g., difficulties with erection or
ejaculation, irregular menses)– 1 or more of pseudoneurological symptoms (e.g., paralyzed muscles,
trouble swallowing, loss of voice, double vision)
clinical presentation – histrionic - la belle indifference
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5 types of somatoform disorders
3) Hypochondriasis
belief that one has a serious disease (e.g., brain cancer) minimum 6 month duration These ideas are not delusional (as in Delusional Disorder)
and are not restricted to concern about appearance (as in Body Dysmorphic Disorder).
They cause distress that is clinically important or impair work, social or personal functioning.
“doctor shopping”
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5 types of somatoform disorders
4) Pain Disorder
preoccupation with pain symptoms complaints seem obsessive - last at least 6 months no known biological origin The person's presenting problem is clinically important pain in one
or more body areas. The pain causes distress that is clinically important or impairs
work, social or personal functioning.
Psychological factors seem important in the onset, maintenance, severity or worsening of the pain.
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5 types of somatoform disorders
5) Body Dysmorphic Disorder preoccupation with an imagined physical
defect common complaints:
– nose, mouth, ears
common result:– unnecessary plastic surgeries
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Diagnosing Somatoform Disorders
First rule out intentional deception– Malingering
Feigning condition for external gain
– Factitious Disorder Intentionally feigning condition
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False Symptoms Can Be Intentional: Factitious Disorders
also called Munchausen’s Syndrome motivation is conscious and to assume the
sick role no other incentives (money, attention, etc.)
present Munchausen’s by proxy: intentionally
induce sickness in one’s child to assume the sick role!
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Etiology
Biological factors– possibility of misdiagnosis
Psychological factors– imagined or real trauma – primary gain (symptoms may function to protect conscious
mind)– secondary gain (symptoms may help patient to avoid
responsibility)
Social factors– culturally-specific anxiety
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Treatment of Somatoform Disorders
Traditionally, little empirical testing Cognitive-behavioural approach
– Pain Disorder: reward successful coping
Medical approach– antidepressants
need for physician empathy
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Case Study: Lt.-Gen. Roméo Dallaire
PTSD due to trauma during Rwandan conflict (1993-1994)
Largely helpless during the genocide Fired upon, received death threats,
witnessed massacre of staff Now prominent advocate for treatment of
PTSD in Canadian military